ARTICLE IN PRESS

International Journal of Nursing Studies ] (]]]]) ]]]]]]

www.elsevier.com/locate/ijnurstu

Burnout, role conict, job satisfaction and psychosocial health

among Hungarian health care staff: A questionnaire survey
Bettina F. Piko
The University of Szeged, Department of Psychiatry, Behavioural Sciences Group, Szeged, Hungary

Abstract

Background: There is a growing interest in the psychosocial work environment of health care staff since they are at
high risk for burnout, role conict and job dissatisfaction. Burnout, as a type of prolonged response to chronic job-
related stressors, has a special signicance in health care where staff experience both psychologicalemotional and
physical stress. Burnout and the other negative aspects of the job of health care staff have major behavioural and health
implications.
Objectives: The present study investigated the interrelationships among burnout, role conict and job satisfaction in a
sample of Hungarian health care staff. The study also investigated how these indicators of psychosocial work climate
inuence respondents frequency of psychosomatic symptoms.
Design: A questionnaire survey (anonymous questionnaires) has been carried out to detect these interrelationships.
Settings: Two major hospitals in Szeged, Hungary.
Participants: Questionnaires were distributed to 450 health care staff among whom 55.7% were registered nurses. All
together, 201 questionnaires were returned and analyzed, giving a response rate of 44.6%.
Methods: Questionnaire contained items on work and health-related information (i.e., burnout, job satisfaction, role
conict, and psychosomatic symptoms) and on some basic sociodemographics. Beyond descriptive statistics, correlation
and multiple regression analyses were computed.
Results: Findings show that emotional exhaustion and depersonalization scores were higher, while scores on personal
accomplishment was lower as compared to Canadian, Norwegian or US samples. Burnout, particularly emotional
exhaustion (po:001), was found to be strongly related to job dissatisfaction. Schooling was inversely related to
satisfaction with the job (po:05). While job satisfaction was a negative predictor of each type of burnout subscale
(po:001), role conict was a factor contributing positively to emotional exhaustion (po:001) and depersonalization
scores (po:001).
Conclusions: The study results underline the importance of the role of psychosocial work environment and the
interrelationships among burnout, role conict, job satisfaction and psychosomatic health among Hungarian health
care staff.
r 2005 Published by Elsevier Ltd.

Keywords: Job satisfaction; Burnout; Role conict; Health care staff; Psychosocial health

What is already known about the topic?

Tel.:/fax: +36 62 420 530.
Health care staff are at high risk for burnout, role
E-mail address: pikobettina@yahoo.com. conict and job dissatisfaction;

0020-7489/$ - see front matter r 2005 Published by Elsevier Ltd.

doi:10.1016/j.ijnurstu.2005.05.003

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Job satisfaction, which is usually lower among health
care staff as compared with other types of organiza-
tions, has a major inuence on job-related beha-
viours such as intentions to turnover, absenteeism,
and self-reported job performance;

These negative aspects of the job of health care staff
have major behavioural and health implications (e.g.,
harmful habits or psychosomatic symptoms) as a
consequence.
What this paper adds?

Study results support the interrelationships among
burnout, role conict, job satisfaction and psychoso-
matic health among health care staff;

Based on the results, psychosomatic symptoms also
may be considered as an important indicator of
professional burnout;

Findings draw the attention to the importance of
improving the psychosocial work environment
among Hungarian health care staff where examining
job satisfaction or burnout syndromes has not yet
received priority thus far.
1. Introduction
Health care staff are at high risk for burnout, role
conict and job dissatisfaction, and probably because of
this, a growing interest in the psychosocial work
environment has been detected in the last few decades
(Tyler and Cushway, 1995). Studies usually nd a
negative relationship between burnout and work satis-
faction, and both experiences are strongly determined by
organizational structures and processes (Burisch, 2002;
Kalliath and Morris, 2002; Stechmiller and Yarandi,
1993; Thomsen et al., 1999).
Burnout is a syndrome of emotional exhaustion,
depersonalization and diminished personal accomplish-
ment that has been recognized as an occupational hazard
for various people-oriented professions, such as social
services, health care or education (Maslach, 1976;
Maslach and Goldberg, 1998). Burnout is a type of
prolonged response to chronic job-related stressors, and
therefore, it has a special signicance in health care
where staff experience both psychologicalemotional and
physical stress (Beckstead, 2002; Shamian et al., 2001;
Wheeler and Riding, 1994). There is also an important
cultural context for occupational stress processes
(Schwartz, 1999). Various social, political and economic
factors shape the health care environment, e.g., changes
in public policy, cutbacks in government funding, etc.
(Maslach and Goldberg, 1998; Murray, 2002).
One important organizational factor that inuences
psychosocial work climate and generates job-related
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stress is role conict (Fenlason and Beehr, 1994;
Kalliath and Morris, 2002). Lack of congruent expecta-
tions and demands from other people in the workplace
are psychologically uncomfortable and may induce
negative emotional reactions, diminish effectiveness
and job satisfaction, and decrease the employees intent
to remain a member of the organization (Allen and
Mellor, 2002; Burke, 2002; ODriscoll and Beehr, 1994).
Job satisfaction has been found to have a major
inuence on job-related behaviours such as intentions to
turnover, absenteeism, and self-reported job perfor-
mance (Nagy, 2002). Job satisfaction has a special
implication for health care service. Among health care
staff job satisfaction is usually lower as compared with
other types of organizations (Glisson and Durick, 1988).
Moreover, low levels of job satisfaction are related to
nurses high turnover and the nursing shortage (Murray,
2002; Oermann, 1995; Tumulty et al., 1994).
All these negative aspects of the job of health care
staff have major behavioural and health implications as
a consequence (Piko, 1999; Shamian et al., 2001;
Trinkoff and Storr, 1998; Wahlstedt and Edling, 1994).
The frequency of psychosomatic symptoms seems to be
a good indicator of health problems that often stem
from challenging psychosocial processes (Piko et al.,
1997), e.g., from job-related stress and dissatisfaction
(Eells et al., 1994; Gonge et al., 2002). All in all,
psychosomatic health complaints have been found to be
quite frequent among nurses (Escriba-Aguir et al., 1993;
Piko, 1999).
These issues seem to be extraordinarily important in a
society in post-socialist transition where the nursing
profession is undergoing dramatic changes as a part of
an ongoing reform (Piko, 2000). In Hungary since 1989,
enormous changes have taken place in the health care
system, which are strongly associated with the countrys
socio-economic transformation. Health care reform
includes many components such as policy-making,
ownership, nancing, management, service structure,
patients rights, medical and nursing education, etc.
Programs in particular have addressed the issues of
resource allocation and rationing health care thus far,
therefore, there have been drastic cuts in both social
welfare and health care expenditures. Inadequate nan-
cing of the health care system in the communist era
resulted in low salaries for health care staff, and
especially for nurses, which today still remain low. Not
surprisingly, there is a tendency among nurses to leave
their profession. Those who choose to remain should
face not only the nancial problems but also the burdens
of psychosocial work environment.
In the present climate of the health care changes, there
is a shortage of research on nurses burnout and job
satisfaction. The relationship between occupational
stress and nurses psychosocial health has already been
studied (Piko, 1999). In this next phase of exploratory
 ARTICLE IN PRESS
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research, we aim at detecting whether psychosomatic
health problems might be a good indicator of nurses
burnout experiences in a changing work climate. There-
fore, the main goal of the present study has been (1) to
investigate in a sample of Hungarian health care staff
the interrelationships among burnout, role conict and
job satisfaction, and (2) to detect how these indicators of
psychosocial work climate inuence respondents fre-
quency of psychosomatic symptoms.
2. Method
2.1. Sample and procedure
Respondents for this study were selected from two
major hospitals in Szeged, Hungary. Besides university
hospitals, these two sites provide health care for people
in and around Szeged. Anonymous questionnaires were
distributed to 450 health care staff (the total number of
health care staff working in various hospital units),
among whom 55.7% were registered nurses, the others
had various paramedical jobs like assistants, physicians
or nurses aides. The questionnaires were delivered to
and collected in staff meetings in all hospital units by
trained sociology students over a 4-week period.
Response rate from the two organizations was 44.6%.
Though these limitations (e.g., the sampling strategy
used and the poor response rate) may lower the
generalizibility of results, they even represent psychoso-
cial problems of the Hungarian hospital staff to a certain
degree. This response rate was lower than expected but
could be explained by low motivation of health care staff
stemming from uncertainty and psychosocial stress due
to the ongoing reform. All together, 201 questionnaires
were returned and analyzed. Demographic character-
istics of the sample are shown in Table 1.
2.2. Instrument
Self-completed questionnaires were used to collect
data on work and health-related information, and on
some basic sociodemographics. Work-related question-
naires that had come from international studies were

Table 1
Demographic characteristics of sample

N % N %

Age Employment status

Under 25 47 23.4 Registered nurse 112 55.7
2630 31 15.4 Head nurse 11 5.5
3135 24 11.9 Assistant to physician 40 19.9
3640 24 11.9 Administrator 9 4.5
4145 19 9.5 Nurses aids 7 3.5
4650 16 8.0 Other health care staff 22 10.9
51 or above 20 10.0
Marital status Years in health care
Single 49 24.4 Under 5 years 47 23.4
Divorced 35 17.4 610 years 33 16.4
Widowed 10 5.0 1120 years 54 26.9
Married 89 44.3 21 or more 62 30.8
Living with a spouse 16 8.0
Schoolinga Work schedule
Primary school 10 5.0 Permanent morning 83 41.3
Secondary technical school 33 16.4 Permanent night 9 4.5
Secondary modern school 90 44.8 Rotating day 21 10.4
Grammar school 47 23.4 Rotating night 85 42.3
College degree 18 9.0
Sex
Male 23 11.4
Female 178 88.6

Note. Percentages do not add up to 100% in most cases due to some missing values or rounding.
a
In Hungary, there are three forms of secondary school after eight years of primary schooling. A grammar school (4 years) provides
a general certicate of education for those wanting to go on to a university/college. A secondary modern school (45 years) provides
both a general certicate of education and some technical qualication for learning a trade. Finally, a secondary technical school (3
years) provides only for some technical qualication for learning a trade without a general certicate of education.

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translated from English into Hungarian and back-
translated by bilingual translators. Finally, a consensus
was formed to produce the nal translation.
The following sociodemographic variables were exam-
ined in the study: age, sex, marital status, schooling,
employment status, work schedule and number of years
employed in health care.
3. Work-related variables
Burnout was measured using the Maslach Burnout
Inventory (MBI; Maslach and Jackson, 1981), which has
been widely used in Hungarian studies. This is a 22-item
measure containing three subscales: emotional exhaus-
tion, depersonalization and personal accomplishment.
More burnout is indicated by higher scores on emotional
exhaustion and depersonalization, and lower scores on
personal accomplishment. Internal consistency was
measured using Cronbachs a with reliability coefcients
of 0.84 for emotional exhaustion, 0.46 for depersonali-
zation and 0.76 for personal accomplishment with the
present sample. Although the depersonalization subscale
had low reliability, this is consistent with a previous
study from Norway (Richardsen et al., 1992), in which
Cronbachs a alpha for depersonalization was the lowest
(0.51) and the a for emotional exhaustion was the
highest (0.84).
Job satisfaction was measured by four items (Beehr et
al., 1990). Previous studies support the usefulness of
using global or even single-item measures of job-
satisfaction instead of multi-scale measurements (Nagy,
2002). In our study, each of the four items measured
global assessment of the job rather than judgments of
specic aspects (e.g., All in all, how satised would you
say you are with your job? or If a friend of yours told
you he/she was interested in working in a job like yours
what would you tell him/her?) The scores were summed
and thus the nal scale had a range of 412 and was
reliable with a Cronbachs a of 0.74.
Role conflict was ascertained by four items dealing
with conicting demands, unreasonable job pressures
and incompatible requests from people in work setting
(Fenlason and Beehr, 1994). Respondents reported how
often they had faced problems indicated by items (e.g.,
I receive incompatible requests from two or more
people or My superiors ask me to do tasks that
conict with one another). Response categories were
very often (5), fairly often (4), sometimes (3), occasion-
ally (2) and rarely (1). The nal scale had a range of 420
and was reliable with a Cronbachs a of 0.66.
3.1. Health-related variables
Psychosomatic symptom scale included the following
self-reported symptoms: lower-back pain, tension head-
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ache, sleeping problems, chronic fatigue, stomach
pyrosis, tension diarrhea and heart palpitation. This
measure was used in order to obtain information on the
frequency of these symptoms during the last 12 months
(Piko et al., 1997). Respondents were asked: During the
past 12 months, how often have you had a back-pain?
... etc. Responses were coded as often (3), sometimes (2),
seldom (1), and never (0). The nal scale had a range of
021 and was reliable with a Cronbachs a of 0.80.
4. Results
The descriptive statistics for burnout and other work
and health-related variables are displayed in Table 2.
The mean for emotional exhaustion was slightly lower,
that of depersonalization was slightly higher and the
mean scores for personal achievement was much lower
than data for health care workers in Norway (Richard-
sen et al., 1992). As compared to social service workers
from Canada, both emotional exhaustion and deperso-
nalization were higher among Hungarian health care
staff, while personal achievement was much lower
(Leiter, 1992). Further comparison can be based on
data from groups of US nurses. Both among neonatal
nurses (Oehler et al., 1991) and doctorally prepared
nurses (Jorgensen Dick, 1992), emotional exhaustion
was slightly lower, depersonalization was considerably
lower, and personal accomplishment much higher than
data from Hungarian health care staff. Evaluating
results of the Hungarian health care staff in the frame
of the ranges for low, moderate and high burnout for
each scale as suggested Maslach and Jackson (1981), the
subscales of emotional exhaustion and depersonaliza-
tion showed moderate levels, and scores on personal
accomplishment showed high levels of experienced
burnout.
Table 3 presents a correlation matrix for work and
health-related variables. There were signicant inter-
correlations among burnout subscales. In addition,
Table 2
Descriptive statistics for burnout and other work and health-
related variables
Mean SD
Burnout scale
Emotional exhaustion 24.7 6.2
Depersonalization 9.4 3.3
Personal accomplishment 27.4 4.4
Psychosomatic symptom scale 11.8 5.0
Role conict scale 8.8 3.3
Job satisfaction scale 8.2 1.9
 ARTICLE IN PRESS
B.F. Piko / International Journal of Nursing Studies ] (]]]]) ]]]]]] 5

Table 3
Correlation matrix for work and health-related variables

Variables 2 3 4 5 6

1. Emotion exhaustion .58** .45** .50** .53** .38**

2. Depersonalization .37** .32** .41** .40**
3. Personal accomplishment .18* .43** .23**
4. Psychosomatic symptoms .18* .33**
5. Job satisfaction .18*
6. Role conict

*po:05; **po:01; two-tailed test.

Table 4
Multiple regression estimates for burnout dimensions

Independent variables Emotional exhaustion Depersonalization Personal accomplishment

Gender (1 male) .09a .17**a .26***a

Age .05 .19* .03
Schooling .05 .16* .14*
Role conict .35*** .34*** .11
Job satisfaction .49*** .37*** .38***
Years in health care .11 .07 .06
Constant 30.9*** 14.2*** 15.4***
2
Adjusted R .39*** .35*** .24***

*po:05; **po:01; ***po:001.

a
Note: Standardized regression coefcients.

emotional exhaustion positively correlated with the Table 5

psychosomatic symptom scores, role conict, and Multiple regression estimates for psychosomatic symptoms
negatively with job satisfaction. Depersonalization
Independent variables Psychosomatic symptoms
positively correlated with psychosomatic symptoms,
role conict, and negatively with job satisfaction, similar Burnout dimensions
to emotional exhaustion. Personal accomplishment was Emotional exhaustion .46***a
positively associated with job satisfaction, and nega- Depersonalization .15
tively with psychosomatic symptoms, and role conict. Personal accomplishment .05
There was a negative correlation between job satisfac- Other work-related variable
tion and role conict. Role conict .15*
Table 4 shows multiple regression estimates for Job satisfaction .11
burnout subscales. Job satisfaction was a negative, while Years in health care .19*
role conict was a positive predictor of emotional
Sociodemographics
exhaustion and depersonalization. Job satisfaction was
Gender (1 male) .16*
also signicantly (and positively) related to personal Age .15
accomplishment. Gender, age and schooling also pre- Schooling .03
dicted depersonalization. Schooling and gender also
predicted personal achievement: females and better- Constant 8.9
educated workers tended to report lower levels of Adjusted R 2
.32***
depersonalization and higher levels of personal accom-
plishment. Sociodemographics, role conict, and job *po:05; **po:01; ***po:001.
a
satisfaction explained 39% of variation in emotional Note: Standardized regression coefcients.
exhaustion, 35% in depersonalization and 24% in
personal accomplishment. only emotional exhaustion was a signicant predictor of
Table 5 shows multiple regression estimates for psychosomatic symptoms. Role conict and the number
psychosomatic symptoms. Of three burnout subscales, of years employed in health care also were signicant

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Table 6 health (Piko, 1999; Richardsen et al., 1992; Trinkoff and

Multiple regression estimates for job satisfaction
Independent variables Job satisfaction
Burnout dimensions
Emotional exhaustion .40***a
Depersonalization .18*
Personal accomplishment .20*
Other work-related variable
Role conict .13
Years in health care .09
Sociodemographics
Gender (1 male) .13*
Age .03
Schooling .12*
Constant 7.5***
Adjusted R 2
.33***

po:05;  po:01;  po:001:
a
Note: standardized regression coefcients.
contributors. Females tended to report higher frequency
of psychosomatic symptoms. Variables explained 32%
of the total variation in psychosomatic symptoms.
Table 6 presents multiple regression estimates for job
satisfaction. All of the burnout subscales were signicant
predictors, particularly emotional exhaustion. This was
the most important factor contributing to job satisfac-
tion among health care staff. Among sociodemo-
graphics, females and workers with higher educational
levels reported lower levels of job satisfaction. Variables
explained 33% of the variation in job satisfaction.
5. Discussion
The main goal of the present study has been to
investigate relationships among burnout, role conict,
job satisfaction and some health-related variables in a
sample of Hungarian health care staff. Despite the fact
that the Hungarian health care system is now under-
going tremendous changes due to health care reforms,
psychosocial work climate and the role of structural
changes in the job-related experiences (see e.g., Piko,
2000), few studies have investigated these issues thus far.
In particular there is a shortage of research on nurses
experiences of burnout and their psychosocial health.
Literature suggests that there are strong interrelation-
ships among low levels of job satisfaction, the burnout
syndrome and other organizational factors (Burisch,
2002; Kalliath and Morris, 2002; Shamian, et al., 2001;
Stechmiller and Yarandi, 1993). Moreover, these nega-
tive aspects of work situations, as a consequence of
occupational stress, may have an effect on employees
Storr, 1998; Wheeler and Riding, 1994).
Burnout is a central feature of occupational stress
(Beckstead, 2002; Maslach, 1976; Maslach and Gold-
berg, 1998). Our ndings show that of its three
subscales, emotional exhaustion and depersonalization
scores were higher, while scores on personal accomplish-
ment was lower as compared to Canadian, Norwegian
or US samples (Jorgensen Dick, 1992; Leiter, 1992;
Oehler et al., 1991; Richardsen et al., 1992). Therefore,
we conclude that this sample of Hungarian health care
staff experience relatively high levels of burnout.
Psychosomatic health complaints were found to be
related to work-related stress (Piko, 1999; Wahlstedt
and Edling, 1994). Based on our results, psychosomatic
symptoms also may be considered as an important
indicator of professional burnout. Both correlation
analyses and multiple regression analyses revealed a
strong relationship between burnout and psychosomatic
symptoms. In addition, experiencing role conict and
number of years employed in health care also were
related to the frequency of psychosomatic symptoms,
while female workers tend to report higher levels of
symptoms as usual (Piko et al., 1997).
Burnout, particularly emotional exhaustion, was also
strongly related to job dissatisfaction, similarly to
previous studies (e.g., Kalliath and Morris, 2002).
Furthermore, schooling was inversely related to satisfac-
tion with the job, i.e., those with better education were
less satised with their jobs. While job satisfaction was a
(negative) predictor of each type of burnout subscale,
role conict was a factor contributing positively to
emotional exhaustion and depersonalization scores.
Schooling may inuence not only job satisfaction but
also levels of depersonalization (negatively) and perso-
nal accomplishment (positively). It seems to be that
educational level may be an important protective factor
against some negative job-related experiences, though
job satisfaction might be lower based on elevated
expectations on the job (Jorgensen Dick, 1992; Oer-
mann, 1995).
These results draw our attention to the importance of
improving the psychosocial work environment among
Hungarian health care staff. Despite the fact that a
number of studies revealed that work environment
inuenced the practice of health care (e.g., Allen and
Mellor, 2002; Murray, 2002; Tumulty et al., 1994),
examining job satisfaction and burnout syndromes has
not yet received priority thus far in the Hungarian
research projects. The most important strength of our
paper is that using internationally well-known measure-
ments, it is possible to interpret our ndings in light of
international data.
Findings presented in this paper should be considered
in light of some limitations. One, as mentioned in the
method section, the sampling strategy used and the poor

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 ARTICLE IN PRESS
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response rate may lower the generalizibility of results.
Two, the cross-sectional study design does not allow us
to establish causal relationships among the variables.
Despite these limitations, however, our results may even
contribute to the development of health care reform by
providing information on burnout, job satisfaction and
role conicts in a sample of health care staff. Our results,
hopefully, may also stimulate further, larger scale
research including more possible predictors in the
models such as working hours and job control.
The study results underline the importance of the role
of psychosocial work environment and the interrelation-
ships among burnout, role conict, job satisfaction and
psychosomatic health among health care staff. Our results
suggest that improvement in this eld should be a priority
intervention, that is, specic interventions should be
planned to help prevent job burnout, low levels of job
satisfaction and subsequent turnover. Information on
psychosocial work climate may provide a good basis for
such an intervention. From a practical perspective, the
issues addressed here are central to changes in manage-
ment practices in hospitals of Hungary which should be
an integrated part of the ongoing reform.
Acknowledgements
The author thanks Terry A. Beehr (Central Michigan
University, Mt. Pleasant, MI, USA) for his helpful
comments on an earlier draft of the paper.
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